Psychosocial adjustment of pediatric patients after allogeneic stem cell transplantation

The purpose of this study was to assess the psychosocial adjustment of patients who had been treated with allogeneic stem cell transplantation (SCT) in our clinic. Selection criteria for patients were to be aged 14-30 years at the time of the follow-up, to be at least 2 years post-SCT and to have a very good knowledge of German. Among 31 eligible patients, 26 participated (84% response rate). The patients were between 15 and 27 years old and were on average 7 years (range 2-13) post-SCT. Research instruments consisted of a demographic questionnaire and various subscales of established psychological measures for which data from a sample of bone cancer survivors and population norms were available. About 35% of patients showed high levels of anxiety, 62% appeared to be extremely sensitive and vulnerable, and 35% showed strong, unfulfilled needs in their love lives. In the other domains tested (self-esteem, family and peer relationships, school/vocational performance, etc), no noticeable differences were found between the subjects and comparable populations. There was no significant association between psychosocial outcome and demographic features or clinical data. Our results suggest that patients who underwent SCT in their childhood or adolescence are at risk of developing long-term emotional or social problems. Due to the retrospective design of our study and the small sample size, no predictive factors for psychosocial distress could be identified.

Organ toxicity and quality of life after allogeneic bone marrow transplantation in pediatric patients: a single centre retrospective analysis

One hundred and fifty five pediatric patients underwent allogeneic bone marrow transplantation between 1980 and 1996 in the St Anna Children's Hospital in Vienna with an overall survival of 52.3% (81 patients). Seventy-three patients with a minimum observation time of 1 year (1-13 years, median: 4.6) were analyzed retrospectively for chronic GVHD, organ toxicity (WHO score), growth and pubertal development. Chronic GVHD was diagnosed in 20 patients (27.3%), being extensive in 17 cases. Maximum organ toxicity was WHO III in two patients (3%) and WHO II in 11 patients (15%) 1 year after BMT and WHO III in one patient (2%) and WHO II in five patients (11%) 3 years after BMT. Impaired growth and pubertal development were detected in more than 30% 3 years after BMT. As all patients presented with a Karnofsky or Lansky score of more than 80%, they were asked to complete a questionnaire comprising 12 questions concerning physical state of health and psychosocial state of health. Restricted contacts were classified as imposing a severe handicap by six patients (8%), restriction in mobility and 'normal life activities' by three patients (4%) and two patients classified themselves as severely physically handicapped. Most patients (75%) reported no physical or psychical impairment.

Transplantation of highly purified peripheral blood CD34+ cells from HLA-mismatched parental donors in 14 children: evaluation of early monitoring of engraftment

HLA-mismatched family members may represent an important cell source for patients that require stem cell transplantation but lack both a matched sibling donor and a closely matched unrelated donor. We report the outcome of 19 transplantations from HLA two- or three- loci mismatched parental donors in which 14 pediatric patients with hematological malignancies or other disorders, received a median of 21.5 x 106 (range, 5.4-58) highly purified CD34+peripheral blood stem cells (PBSC), as well as 4.7 x 104 (range, 0.4-12) donor T cells per kg body weight. T cell depletion was performed using a two-step CD34-positive selection on two different magnetic beads devices. Ten of 14 patients presented with rapid myeloid engraftment. The four patients who presented with graft failure (two non-engraftments, two rejections) received a second stem cell graft and one a third. Graft rejection was detected early by polymerase chain reaction (PCR) analysis of FACS-sorted T cells. Eight of the 14 patients are still alive after a median observation period of 15. 6 months (range, 3-31.3) with full donor chimerism in all hematopoietic cell lineages. No acute organ graft-versus-host disease (GVHD) and no chronic GVHD have occurred. One patient experienced relapse of leukemia. We conclude that transplantation of allogeneic PBSC from haploidentical donors will open new perspectives for pediatric patients for whom an HLA-matched stem cell graft is not available. Close monitoring of recipient and donor hematopoiesis might be of clinical value, to recognize early engraftment or rejection.

Resolution of early cytomegalovirus (CMV) infection after leukocyte transfusion therapy from a CMV seropositive donor

A 2 year and 8 month old CMV-negative boy suffering from stage III neuroblastoma underwent ABMT in first very good partial remission. He acquired early CMV infection on day +5, followed by consecutive graft failure and severe sepsis, and the clinical course deteriorated. Between days +16 and +21, he received seven leukocyte concentrates (LC) collected from a healthy, but CMV-IgG-seropositive relative stimulated with G-CSF (filgastrim, 5 microg/kg/day). A median of 5.7 x 10(10) neutrophils/m2/day (range, 1.2-8.3) were transfused, corresponding to a T cell number of roughly 4 x 10(8) CD3+ cells/kg/day. After infusion of the LCs, PCR analysis became negative for CMV and the patient received his rescue bone marrow. One year after ABMT, he is in complete remission and in good clinical condition. Our results suggest that the T cells infused together with the irradiated leukocytes played a major role in eradicating the CMV infection in this patient.

CMV-viraemia during allogenic bone marrow transplantation in paediatric patients: association with survival and graft-versus-host disease

Sixty-one consecutive paediatric patients undergoing allogenic bone marrow transplantation (BMT) were screened prospectively for cytomegalovirus (CMV)-viraemia by PCR. Sixteen patients (26%) presented with single or recurrent CMV-viraemia between day -7 and + 100. Although only four of them had evidence of CMV-disease, there was a significant difference in the incidence of acute Graft versus Host Disease (GVHD) grade III-IV (75% vs 15.5%), liver-involvement (68% vs 13%) and the incidence of chronic GVHD (83% vs 13.8%) between CMV-PCR-positive and CMV-PCR-negative patients. Transplant-related mortality (TRM) was 43.7% in the CMV-PCR-positive group versus 13% in patients which had no evidence for CMV-viraemia. In all but one cases mortality in CMV-PCR positive patients was GVHD-associated. Pre-emptive therapy with gancyclovir in case of CMV-viraemia seemed to have no impact on incidence and severity of GVHD.

[Quality of life and symptoms of residual damage in cerebellar tumors in children and adolescents]

At the departments of neurosurgery and pediatrics of the University Hospital of Hamburg 21 patients after neurosurgery and radiation of cerebellar tumors have been examined as to neuropsychological, neurological and ophtalmological disabilities. A standardized questionairy for the parents concerning different aspects of their children's quality of life (physical, mental, social health and functional limitations) was performed. 16 children showed minor neurological signs with no or mild disability, in 5 children severe disability was found. In 4 patients morphological changes in the eyeground, in 2 patients amblyopia was detected. 19 patients underwent a neuropsychological examination. The group of patients with medulloblastoma or ependymoma (n = 10) scored in nearly all tests below the group with astrocytoma (n = 9). 3 out of 7 patients in the medulloblastoma or ependymoma group had to abandon school, one patient needs special education. All patients with astrocytoma performed fairly well at school. Parents of patients with medulloblastoma or ependymoma classified their children's quality of life not as good as did parents of children with astrocytoma. The amount of objective disability had no influence on the parents estimation of their children's quality of life. Besides the neurological examination the neuropsychological and quality of life assessment proved to be an essential part of follow up. For a more comprehensive understanding of quality of life, qualitative assessment strategies should be included in further research.

[Prognosis and quality of life following tumors in the pineal region in childhood]

At the department of neurosurgery and pediatrics of the University Hospital of Hamburg 18 children with pineal region tumors were treated by surgical removal and craniospinal axis radiation. Total or nearly total removal was achieved in 13 cases. In case of astrocytoma and pineocytoma no further treatment was performed. Children with germinoma, pinealoblastoma and teratoma underwent craniospinal axis radiation postoperatively. All children thus treated, except one with a highly malignant pinealoblastoma, are so far relapse-free. Two patients with germinoma and two patients with malignant mixed teratoma, which showed extensive growth and/or primary metastases already at admission died. Subject of this report is an assessment of quality of live and a comprehensive follow-up of neurological, endocrinological and psychointellectual conditions of the surviving children. Parent assessment of quality of life indicate for all but two children life quality as excellent or reasonable. One child was disabled by severe motor dysfunction, visual defects and convulsions. In two children minor neurological handicap was found. Minor oculomotor dysfunction was the most frequent neurological finding. Four children showed endocrinopathies. In three cases tumor associated panhypopituitarism persisted after treatment. Only one child developed growth hormone and ADH deficit succeeding surgery and craniospinal axis radiation. The children were examined with a neuropsychological test-battery. In four children severe neuropsychological deterioration was found. Three children showed no remarkable deterioration, five only minor or moderate psychological deficits. Generally verbal intelligence seemed to be on average, non-verbal intelligence and ability for concentration showed decreased scores.